If you have any questions about this agreement, contact us at 910-949-4045.

To Whom It May Concern:

I am pleased to welcome you to Triple P (Positive Parenting Program), provided by Partners for Children & Families. It is our goal to provide you with a safe and welcoming space so that together we can connect, explore and address the parenting issues you face and help you feel more confident and competent as the caregiver of your child(ren). Establishing a strong and trusting relationship is important. Your willingness to discuss any concerns with me will support the work that we do together.

During individual sessions where personal situations are shared with me directly, information will be confidential.  During group sessions, confidentiality and respect for one another will be highly encouraged. In all situations, however, I have a duty to report to the appropriate authorities any suspected child abuse, neglect, or dependency.

To prepare for the role of becoming your Triple P coach, I completed the National Triple P training and am now an accredited Triple P Practitioner. I have also completed the Reconnect For Resilience training.   Additionally, I have over 30 years of experience working with young children and their families as an early educator.

Please note, I am not a mental health provider and this service is not intended to replace professional therapy or mental health support. I am unable to provide recommendations on or get involved with issues of child custody or marital separation. If you need documentation confirming participation in this program, I will prepare a letter for you that includes the dates of our interactions and an overview of the Triple P content discussed during our time together.
 
Triple P is one of the few parenting programs in the world with evidence to show it works.  I look forward to supporting you and your family during this important time in your lives.

Respectfully,
Diane Atherton
Triple P Practitioner
Partners for Children & Families
(910) 949-4045
datherton@pfcfmc.org

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* 1. I,_____________________________________, have read this Confidentiality and Disclosure agreement and have been given the opportunity to have any questions answered.

If you would like to participate in this program, please read the statement above and type your FULL NAME in the box below:

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* 2. Mailing address

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* 3. Phone contacts

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* 4. Email address

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* 5. Child's name

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* 6. Child's date of birth

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* 7. Your relationship to this child

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* 8. Does your child experience any of the following?

A vision or hearing impairment?
A severe chronic illness that results in regular hospitalization?
A physical disability?
An intellectual disability?
A developmental delay?
A restrictive diet prescribed by a health professional?
Any other significant health concern?

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* 9. Is your child having any regular visits with another professional or government agency for emotional or behavioral problems?

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* 10. Thank you for sharing this information with me. I look forward to working together. I will contact you soon! How would you like for me to get in touch with you?

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